The importance of administration, management and bureaucracy in healthcare
Examination of last month’s Health Bill has resulted in a renewed attack on NHS managers and the ‘back-office functions’ administration, management and bureaucracy. However, not only are these functions quite separate, they are all still essential, write John Carrier, Chair of NHS Camden, and professor Ian Kendall from the University of Portsmouth.
A predictable by-product of the lengthy Health and Social Care Bill legislation has been a renewal of the attack on NHS managers and back-office functions. To win friends and influence people, there seems to be an open season on public servants as a quick and often unfounded attack on bureaucracy.
This is a useful device for deflecting criticism from substance on to process.
Health service managers are (in our view) often the target of unjustified criticism by being wrongly labelled as administrators or bureaucrats. All three terms seem to be confused in political, public and media minds, yet all are quite distinctive and support the delivery of healthcare through the NHS in different ways.
What, then, are the distinctive qualities of administration, management and bureaucracy?
Administrators follow rules with little discretion allowed. These are the front-line NHS staff who ensure that the business of the service is not obstructed by gaps in procedure or the flow of information. This can be a significant contribution to the delivery of services on agreed criteria.
Managers have been important personnel since the 1983 report by Sir Roy Griffiths, commissioned by the then Thatcher government.
Unlike administrators, they make important discretionary judgements with regard to the allocation of scarce NHS resources. They make critical decisions at the margin where discretion is possible (adapting services to patient/client needs), making not only financial, but also economic, decisions around the opportunity cost of selecting or discontinuing one policy or service over another.
The essence of this discretion is the room for decisional manoeuvre. The skill of NHS managers, as with any public service manager, is to increase the discretionary space within the legal framework for the benefit of users and suppliers of health care.
Both administrators and managers have been labelled pejoratively as bureaucrats working within the tight rules of a rigid and inflexible bureaucracy. However, the true purpose of a bureaucracy, and the work of its officials, is to ensure due process takes place, and that decisions are recorded so that fairness is ensured through precedent.
It should not be forgotten that although Weber described bureaucracy, over one hundred years ago, as an “iron cage”, he also identified positive features.
Current critics may be repeating Merton’s concern (in 1938) about the “dangers of bureaucratic pathology” but such deviant uses of the term bureaucracy should not detract its more positive and safeguarding features, providing the basis for rational administration with an emphasis on record-keeping, accountability, objectivity and precedent without ire.
Public enquiries often implicitly, if not explicitly, hark back to an “if only this decision had been recorded and followed up” type of statement.
We would suggest that in the NHS, all three functions are essential and that negative attitudes on administration, management and bureaucracy are misplaced, ill-judged and substitute criticism of process for intolerance of substance.
This phenomenon is not the preserve of any one political party, but what critics share in common is the inability to distinguish between these aspects. Unless there is more clarity around these distinctions, criticism of process will continue to obscure the unheralded, silent and often invisible work carried out by staff in these public service positions.
This work includes providing for the flow of information and the delivery of standard expectations (administration); the protection and allocation of scarce public resources (management); and providing for due process and adequate record-keeping (bureaucracy). All contribute heavily to public accountability.
As a result, without understanding and valuing these distinctions patient care can be compromised. For evidence of this we could refer to the numerous public enquiries into serious untoward incidents in the NHS and social services in the last 60 years.
Thus administration, management and bureaucracy do have their places in the NHS, and unthinking criticism of all under the misleading and pejorative epithet of bureaucracy does not lead to clear thinking and rational policy-making.